1
|
Xie JX, Gunzburger EC, Kaun L, Plomondon ME, Barón AE, Waldo SW, Virani SS, Maddox TM, Mavromatis K. Medical Therapy Utilization and Long-Term Outcomes Following Percutaneous Coronary Intervention: Five-Year Results From the Veterans Affairs Clinical Assessment, Reporting, and Tracking System Program. Circ Cardiovasc Qual Outcomes 2019; 12:e005455. [PMID: 31665896 DOI: 10.1161/circoutcomes.118.005455] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Optimal medical therapy is endorsed by national guidelines in the management of ischemic heart disease; however, few studies have examined its long-term utilization following percutaneous coronary intervention (PCI) and association with clinical outcomes. We sought to assess longitudinal trends in medical therapy use after PCI and its prognostic significance. METHODS AND RESULTS From the Veteran Affairs Clinical Assessment, Reporting, and Tracking System Program, we retrospectively identified 57 900 Veteran's Affairs patients undergoing PCI from January 2005 to May 2014. Using prescription fill dates, the utilization of 4 classes of medical therapy including statins, β-blockers, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, P2Y12 inhibitors, and their composites were assessed at discharge, 6 months, 1, 3, and 5 years post-PCI. Multivariable Cox regression models were developed to assess the association between medical therapy status and major adverse cardiovascular events, defined as all-cause mortality, rehospitalization for myocardial infarction, rehospitalization for stroke, or repeat revascularization. At discharge following PCI, 58.3% of patients received all 4 classes of medical therapy. Utilization of statins, β-blockers, and angiotensin-converting enzyme inhibitors/angiotensin receptor blockers decreased from 89%, 84.9%, and 72.2% on discharge, respectively, to 72.7%, 67.9%, and 57.9% at 5 years. Prescription refills of P2Y12 inhibitors declined from 96.5% on discharge to 28.3% at 5 years, driven by a large decline in P2Y12 inhibitor use after 1 year. Use of each class of medical therapy, and its composite use, was associated with a significant reduction in major adverse cardiovascular events at 5 years, with the largest effect size seen by the use of statins (HR, 0.77; 95% CI, 0.75-0.79; P<0.0001) and P2Y12 inhibitors (HR, 0.82; 95% CI, 0.79-0.85; P<0.0001). CONCLUSIONS Consistent declines in medical therapy use following PCI were observed over time, which is associated with worse outcomes. Further efforts are needed to promote long-term adherence to secondary prevention therapies after revascularization.
Collapse
Affiliation(s)
- Joe X Xie
- Emory University School of Medicine, Atlanta, GA (J.X.X., K.M.).,Atlanta VA Medical Center, Decatur, GA (J.X.X., K.M.)
| | - Elise C Gunzburger
- Rocky Mountain Regional Medical Center, Aurora, CO (E.C.G., L.K., M.E.P., S.W.W.)
| | - Lindsay Kaun
- Rocky Mountain Regional Medical Center, Aurora, CO (E.C.G., L.K., M.E.P., S.W.W.)
| | - Mary E Plomondon
- Rocky Mountain Regional Medical Center, Aurora, CO (E.C.G., L.K., M.E.P., S.W.W.)
| | - Anna E Barón
- Department of Biostatistics and Informatics, University of Colorado Anschutz Medical Campus, Aurora (A.E.B.)
| | - Stephen W Waldo
- Rocky Mountain Regional Medical Center, Aurora, CO (E.C.G., L.K., M.E.P., S.W.W.)
| | - Salim S Virani
- Michael E. DeBakey VA Medical Center & Baylor College of Medicine, Houston, TX (S.S.V.)
| | - Thomas M Maddox
- Washington University School of Medicine, St. Louis, MO (T.M.M.)
| | - Kreton Mavromatis
- Emory University School of Medicine, Atlanta, GA (J.X.X., K.M.).,Atlanta VA Medical Center, Decatur, GA (J.X.X., K.M.)
| |
Collapse
|
2
|
Li S, Che G, Liu L, Chen L. Does the "obesity paradox" really exist in lung cancer surgery? -maybe we should recognize what is the "obesity" first. J Thorac Dis 2019; 11:S291-S295. [PMID: 30997201 DOI: 10.21037/jtd.2019.01.34] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- Shuangjiang Li
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu 610041, China.,State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Guowei Che
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Lunxu Liu
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Longqi Chen
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu 610041, China
| |
Collapse
|
3
|
Brostow DP, Warsavage TJ, Abbate LM, Starosta AJ, Brenner LA, Plomondon ME, Valle JA. Mental illness and obesity among Veterans undergoing percutaneous coronary intervention: Insights from the VA CART program. Clin Obes 2019; 9:e12300. [PMID: 30793500 DOI: 10.1111/cob.12300] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Revised: 01/09/2019] [Accepted: 01/12/2019] [Indexed: 12/22/2022]
Abstract
Mental illness and obesity are highly prevalent in patients with coronary disease and are frequently comorbid. While mental illness is an established risk factor for major adverse cardiac and cerebrovascular events (MACCEs), prior studies suggest improved outcomes in people with obesity. It is unknown if obesity and mental illness interact to affect cardiac outcomes or if they independently influence MACCE. We identified 55 091 patients undergoing percutaneous coronary intervention (PCI) between 2009 and 2014, using the Veterans Affairs (VA) Clinical Assessment Reporting and Tracking (CART) program. Cox methods were used to assess the risk of MACCE by weight status and psychiatric diagnosis, and assessed for interaction. Compared to normal weight status, higher weight was associated with reduced MACCE events after PCI (mean follow-up of 2 years) for both stable angina and acute coronary syndromes (ACSs; reduction of >13% in stable angina, >17% in ACS; P < 0.01 for both after adjustment). Having a non-substance abuse mental illness diagnosis increased risk of MACCE compared to patients without mental illness in stable angina over 17%; P < 0.05, but not in ACS. When analysed for interaction, obesity and mental illness did not significantly impact MACCE over their independent influences. These results suggest that mental illness along with weight status have significant impact on MACCE, post-PCI. Clinicians should be aware of patients' mental health status as a significant cardiovascular risk factor after PCI, independent of weight status.
Collapse
Affiliation(s)
- Diana P Brostow
- Rocky Mountain Regional VA Medical Center, Denver-Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Aurora, CO, USA
- Department of Physical Medicine and Rehabilitation, Anschutz School of Medicine, University of Colorado, Aurora, CO, USA
| | - Theodore J Warsavage
- Rocky Mountain Regional VA Medical Center, Denver-Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Aurora, CO, USA
| | - Lauren M Abbate
- Geriatric Research, Education, and Clinical Center, Rocky Mountain VA Medical Center, Aurora, CO, USA
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Amy J Starosta
- Department of Rehabilitation Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Lisa A Brenner
- Department of Physical Medicine and Rehabilitation, Anschutz School of Medicine, University of Colorado, Aurora, CO, USA
- Rocky Mountain VA Medical Center, Rocky Mountain Mental Illness Research Education and Clinical Center, Aurora, CO, USA
- Department of Psychiatry, Anschutz School of Medicine, University of Colorado, Aurora, CO, USA
- Department of Neurology, Anschutz School of Medicine, University of Colorado, Aurora, CO, USA
| | - Mary E Plomondon
- Rocky Mountain Regional VA Medical Center, Denver-Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Aurora, CO, USA
| | - Javier A Valle
- Division of Cardiology, Anschutz School of Medicine, University of Colorado, Aurora, CO, USA
| |
Collapse
|
4
|
Hira RS, Kataruka A, Akeroyd JM, Ramsey DJ, Pokharel Y, Gurm HS, Nasir K, Deswal A, Jneid H, Alam M, Ballantyne CM, Petersen LA, Virani SS. Association of Body Mass Index With Risk Factor Optimization and Guideline-Directed Medical Therapy in US Veterans With Cardiovascular Disease. Circ Cardiovasc Qual Outcomes 2019; 12:e004817. [PMID: 30636483 DOI: 10.1161/circoutcomes.118.004817] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Obesity is a growing epidemic that has been linked to the development of cardiovascular disease (CVD). Guideline-directed medications for secondary prevention and risk factor control are recommended for patients with all forms of CVD. The association of body mass index (BMI) with use of medications for secondary prevention and risk factor control in patients with CVD are poorly understood. METHODS AND RESULTS We identified 1 122 567 patients with CVD receiving care in 130 Veterans Affairs facilities from October 1, 2013, to September 30, 2014. Five groups were stratified by BMI-underweight (BMI, <18.5 kg/m2), normal (BMI, 18.5-24.9 kg/m2), overweight (BMI, 25-29.9 kg/m2), obese (BMI, 30-39.9 kg/m2), and extremely obese (BMI, ≥40 kg/m2). A composite of 4 measures-blood pressure <140/90 mm Hg, hemoglobin A1c ≤9% in diabetic patients, statin use, and antiplatelet use-termed optimal medial therapy (OMT) was compared among groups. Multivariable logistic regression was performed with normal BMI as the referent category. Underweight patients comprised 12 623 (1.1%), normal BMI 230 471 (20.5%), overweight 413 590 (36.8%), obese 404 105 (36%), and extremely obese 61 778 (5.5%) of the cohort. Only 43.7% of the entire cohort received OMT, and this was the highest in the overweight group. Adjusted odds ratios for receiving OMT were 0.81 (95% CI, 0.77-0.85), 1.11 (95% CI, 1.10-1.13), 1.08 (95% CI, 1.06-1.09), and 0.87 (95% CI, 0.85-0.89), for patients who were underweight, overweight, obese, and extremely obese, respectively, compared with normal BMI. CONCLUSIONS OMT was low in the entire cohort. There is an inverse U-shaped relationship between OMT and BMI with patients who are underweight and extremely obese less likely to receive OMT compared with patients with normal BMI.
Collapse
Affiliation(s)
- Ravi S Hira
- University of Washington, Seattle (R.S.H., A.K.)
| | | | - Julia M Akeroyd
- Health Policy, Quality and Informatics Program, Michael E. DeBakey Veteran Affairs Medical Center Health Services Research and Development Center for Innovations, Houston, TX (J.M.A., L.A.P., S.S.V.)
| | - David J Ramsey
- Section of Health Services Research, Department of Medicine (D.J.R., L.A.P., S.S.V.), Baylor College of Medicine, Houston, TX
| | - Yashashwi Pokharel
- Section of Cardiovascular Research, Department of Medicine, Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City (Y.P.)
| | | | | | - Anita Deswal
- Michael E. DeBakey VA Medical Center, Houston, TX (A.D., H.J., L.A.P., S.S.V.).,Baylor College of Medicine, Houston, TX (A.D., H.J., M.A., C.M.B., L.A.P., S.S.V.)
| | - Hani Jneid
- Michael E. DeBakey VA Medical Center, Houston, TX (A.D., H.J., L.A.P., S.S.V.).,Baylor College of Medicine, Houston, TX (A.D., H.J., M.A., C.M.B., L.A.P., S.S.V.)
| | - Mahboob Alam
- Baylor College of Medicine, Houston, TX (A.D., H.J., M.A., C.M.B., L.A.P., S.S.V.)
| | - Christie M Ballantyne
- Section of Cardiovascular Research, Department of Medicine (C.M.B.), Baylor College of Medicine, Houston, TX.,Baylor College of Medicine, Houston, TX (A.D., H.J., M.A., C.M.B., L.A.P., S.S.V.).,Center for Cardiovascular Prevention, Methodist DeBakey Heart and Vascular Center, Houston, TX (C.M.B.)
| | - Laura A Petersen
- Health Policy, Quality and Informatics Program, Michael E. DeBakey Veteran Affairs Medical Center Health Services Research and Development Center for Innovations, Houston, TX (J.M.A., L.A.P., S.S.V.).,Section of Health Services Research, Department of Medicine (D.J.R., L.A.P., S.S.V.), Baylor College of Medicine, Houston, TX.,Michael E. DeBakey VA Medical Center, Houston, TX (A.D., H.J., L.A.P., S.S.V.).,Baylor College of Medicine, Houston, TX (A.D., H.J., M.A., C.M.B., L.A.P., S.S.V.)
| | - Salim S Virani
- Health Policy, Quality and Informatics Program, Michael E. DeBakey Veteran Affairs Medical Center Health Services Research and Development Center for Innovations, Houston, TX (J.M.A., L.A.P., S.S.V.).,Section of Health Services Research, Department of Medicine (D.J.R., L.A.P., S.S.V.), Baylor College of Medicine, Houston, TX.,Michael E. DeBakey VA Medical Center, Houston, TX (A.D., H.J., L.A.P., S.S.V.).,Baylor College of Medicine, Houston, TX (A.D., H.J., M.A., C.M.B., L.A.P., S.S.V.)
| |
Collapse
|
5
|
Flegal KM, Ioannidis JPA. The Obesity Paradox: A Misleading Term That Should Be Abandoned. Obesity (Silver Spring) 2018; 26:629-630. [PMID: 29570246 DOI: 10.1002/oby.22140] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Revised: 01/09/2018] [Accepted: 01/13/2018] [Indexed: 01/09/2023]
Abstract
The term "obesity paradox" is a figure of speech, not a scientific term. The term has no precise definition and has been used to describe numerous observations that have little in common other than the finding of an association of obesity with a favorable outcome. The terminology has led to misunderstandings among researchers and the public alike. It's time for authors and editors to abandon the use of this term. Simply labeling counterintuitive findings as the "obesity paradox" adds no value. Unexpected findings should not be viewed negatively; such findings can lead to new knowledge, better treatments, and scientific advances.
Collapse
Affiliation(s)
- Katherine M Flegal
- Stanford Prevention Research Center, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - John P A Ioannidis
- Stanford Prevention Research Center, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
- Department of Health Research and Policy and Department of Biomedical Data Science, Stanford University School of Medicine, Stanford, California, USA
- Department of Statistics, Stanford University School of Humanities and Sciences, Stanford, California, USA
- Meta-Research Innovation Center at Stanford (METRICS), Stanford University, Stanford, California, USA
| |
Collapse
|